Ordering/Referring Denial Edits

Ordering/Referring Denial Edits

Effective January 6, 2014, the Centers for Medicare & Medicaid Services (CMS) turned on claim processing edits for the expansion of the scope of editing for ordering/referring providers to deny Part B diagnostic laboratory and imaging claims. Claims identified or defined as diagnostic laboratory and imaging services (i.e., EKGs) will deny if the ordering or referring provider’s information is missing, invalid or if the provider is not of a specialty that is eligible to order and refer. Claims submitted identifying the ordering or referring provider information missing the matching NPI will be rejected.

Additional information can be found in the MLN Matters Article SE1305.

Administrative Simplification Compliance Act (ASCA) Denials Have No Appeal Rights

Administrative Simplification Compliance Act (ASCA) Denials Have No Appeal Rights

Claims denied with a Medicare Remittance Advice message M117, "Not covered unless submitted via electronic claims," are not considered an initial determination. Therefore, claims with this denial message do not have an appeal right. The ASCA requires that providers submit claims to Medicare electronically, with a limited number of exceptions. Do not request an appeal. These services must be resubmitted electronically to be considered for payment. For additional information on ASCA please refer to "Administrative Simplification Compliance Act (ASCA)."

 

Claims Denied Based on the Timely Filing Limit Do Not Have Appeal Rights

Claims Denied Based on the Timely Filing Limit Do Not Have Appeal Rights

When a claim is denied for having been filed after the timely filing period (12 months or 1 calendar year), such denial does not constitute an "initial determination." As such, the determination is not subject to appeal. Appeal requests will be dismissed due to no initial determination. For additional information on timely filing requirements or potential reasons for extending this timeframe, please refer to "Timely Filing of Claims."

 

Two New CMS Secure Net Access Portal (C-SNAP) Features Coming Soon!

Two New CMS Secure Net Access Portal (C-SNAP) Features Coming Soon!

Clerical Error Reopens: There will be a change to how reopening requests will be accepted by WPS Medicare via the C-SNAP. You will no longer have to complete the Reopening Request form, but rather you will have the opportunity to make an adjustment to your claim.

Overpayment Claim Adjustments: Medicare Part B providers will have an automated process to submit Medicare Secondary Payer (MSP) and non-MSP overpayment adjustments via C-SNAP.

 

Ordering/Referring Denial Edits ASCA Denials Late Filed Claims C-SNAP

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